1. health and fitness
2. disease

INTERNAL MEDICINE
CLERKSHIP MANUAL
CLASS OF 2016
(7/28/2014 to 7110/2015)
Table of Contents
Key Contacts ............................................................ Page 3
Course Objectives ...................................................... Page 4
Numbers & Kinds of Patients .......................................... Page 6
Evaluations/Clerkship Evaluation ...................................... Page 10
Remediation/Failure to meet evaluation standards .................. Page 18
Attendance Policy/Absences ............................................ Page 19
Failure to meet attendance requirements .............................. Page 19
Inpatient service responsibilities/On-call expectations .............. Page 20
Sandersville ................................................................ Page 21
Outpatient service responsibilities ...................................... Page 22
Directions to The Hope Center .......................................... Page 24
H&P workups .............................................................. Page 27
Duty hour expectations/Curriculum .................................... Page 30
Curriculum .................................................................. Page 31
Important Dates & Information ........................................ Page 32
Physical Findings .......................................................... Page 34
Clerkship syllabus ......................................................... Page 35
Mission, Vision, Goals .................................................... Page 36
Grading Information ...................................................... Page 37
Work hours/Procedure Log ............................................... Page 39
On Call Holiday Schedule ................................................ Page 41
Appendix ............................................................................ Page 44
Page 12
INTERNAL MEDICINE ACADEMIC YEAR 2014-2015
CLASS OF 2016
JUNIOR MEDICINE CLERKSHIP DESCRIPTION
Welcome to the Internal Medicine Clerkship!
The following are the key faculty and staff who are responsible for the Clerkship.
Clerkship Director: Rossana Carter, MD
Phone: (478) 957-1847; E-mail: [email protected]
Assistant Clerkship Director: Thomas Hope, MD
Phone: (478) 461-4622 ; E-mail: [email protected]
Clerkship Coordinator: Mrs. Kymberli Hillman
Phone: (478) 301-5840 ; E-mail : [email protected]
Pager: (478) 633-2002; ID # 2868
Residency Program Director: Edwin Grimsley, MD
Phone: (478) 301-5820 ; E-mail : [email protected]
Associate Residency Program Director: Lisa Snellgrove , MD
Phone: (478) 301-5820 ; E-mail: [email protected]
Interim Department Chair: John A. Hudson , MD
Phone: (478) 301-5820 ; E-mail: [email protected]
Office Address:
Department of Internal Medicine
Junior Medicine Clerkship
707 Pine Street * Macon, GA 31201
Chief Residents
2014-2015
NAMES
PAGERS
Luke Williams, MD 3rd Yr.
4 78-633-2002 ID# 1549
Ryan Nadelson , MD 3rd Yr.
478-633-2002 ID# 1511
Page / 3
THE COURSE OBJECTIVES OF THE CLERKSHIP ARE AS FOLLOWS:
The student will be able to ...... .
1. Obtain a complete and accurate medical history including asking how recently patient has
undergone appropriate screening studies.
2. Obtain an accurate social/health promotion history including asking about alcohol,
tobacco, exercise, etc.
3. Perform and record a complete and accurate physical.
4. Review laboratory tests and radiological studies and interpret possible causes and effects.
5. Develop an accurate assessment, workable problem list and differential diagnosis on each
new patient.
6. Suggest an appropriate therapeutic plan that includes pharmacological agents and
therapeutic diagnostic studies.
7. Recognize and prioritize problems in the form of a problem list.
8. Review pertinent literature to expand your knowledge and understand the natural history
of the disease process and determine the efficacy of traditional and nontraditional
therapies.
9. Communicate effectively in oral and written form.
10. Use electronic data retrieval systems (MD CONSULT, PUB MED, HARRISONS, UP
TO DATE)
11. Recognize and maintain professional conduct.
12. Be active in the role as part of the multidisciplinary team including nurses, social
workers, colleagues, patients, and families.
13. Recognize the ethical and medical issues in patient documentation, confidentiality issues.
14. Discuss patient issues consistent with HIP AA privacy regulations.
15. Recognize situations where biopsychosocial determinants have impact on health and
disease and identify ways to maximize therapy and safe discharge that takes into account
these issues.
16. Identify most appropriate tests in any patient encounter based on documented sensitivity
and specificity and adequately explain decision process to team.
Page/4
17. Rapidly identify life threatening emergencies and notify team of same in a timely fashion.
18. Interact with patients in a manner that respects individual diversity (including religious,
racial, ethnic, sexual orientation, etc.) differences.
19. Interact with patients in a courteous, caring, empathetic manner using standard good
courtesy practice (including active listening, reflective listening, not interrupting, not
judging, etc.)
20. Recognize normal structure and function of normal body systems and recognize
alterations of these body systems in the diseased state.
21. Specific objectives for the cardiology rotation include performing a focused history &
physical exam on cardiac patients presenting with acute coronary syndromes, heart
failure, arrhythmias and pericardia! diseases, discuss differential diagnosis and
management plans with residents and attending including the selection and prioritization
of appropriate laboratory test as well as non-invasive and invasive procedures. Learn the
interpretation of normal electrocardiogram and common abnormalities including
ischemia, hypertrophy, pericarditis, bundle branch block and basic arrhythmias.
22. Specific objectives for the ambulatory infectious disease rotation include those previously
mentioned (1, 3, 4, 5, 6, 9, and 13). In addition, students will learn to develop differential
diagnosis in HIV patients and begin learning to assess infectious vs. non-infectious
illnesses in hospital consult patients.
23. The student will be able to identify an assortment of physical fmdings as listed in the
student manual via the provided website and be responsible for the content of that
website to be tested on the exit exam at the end of the fourth year.
24. Learn basics of acid base balance, differential diagnosis for Acute Kidney Injury and
Chronic Kidney Injury for students rotating in Nephrology during two week selective.
25. For students rotating in Neurology, students will learn basic neurological exam, review
causes of acute embolic/thrombotic strokes and apply basic science knowledge to clinical
situations.
26. Analyze clinical experiences and scientific information and use this information to
improve clinical experience through reflective writing.
27. Participate in an OSCE at mid-rotation and receive feedback on performance by faculty
mentor.
28. The student will learn to recognize common pathological conditions/findings using
diagnostic imaging studies appropriate for the clerkship.
Your own patients are the focus of developing these skills and your contact with them is the center ofyour
curriculum.
Page /5
Number and Kind of Patients
Students Should Encounter During Internal Medicine Clerkship
Cardiovascular System
Encounter
Required
Minimum
Heart Failure
2
Coronary
1
Artery Disease
Hypertension
3
r
En docnno
. 1ogy an dM et abo Ism
Encounter
Required
Minimum
Diabetes
4
Mellitus
Lipid disorders 3
1
Thyroid
diseases
Gas troent ero1ogy an dH epat o1ogy
Encounter
Required
Minimum
Gastrointestinal 1
Bleeding
PUD/GERD
1
Liver diseases
1
Hematology and Oncology
Encounter
Required
Minimum
1
Anemia
Cancer
1
Renal failure
0/P
I or II
I
X or
X or
X
X
I or II
X or
X
Level of Care *
IIP
0/P
I or II
X or
X
I or II
I or II
X or
X or
X
X
IIP
0/P
Level of Care
*
I or II
X
I or II
I or II
X
X
*
IIP
0/P
X or
X
X
IIP
0/P
I or II
I or II
X or
X
X
Required
Minimum
Level of Care *
IIP
0/P
1
I
X
Infectious Diseases
Encounter
Required
.Minimum
HIV infection
1
1
Skin and Soft
tissue infection
N eplhro1ogy
Encounter
*
IIP
Level of Care
Level of Care
I or II
I
Level of Care
*
Page /6
Neurology
Encounter
Stroke
Required
Minimum
1
Preventive Medicine
Encounter
Required
Minimum
Adult
1
Preventive Care
Psychiatric/Psychosocial disorder
Encounter
Required
Minimum
Depression
1
Substance
2
Abuse
Level of Care
*
I or II
VP
X
Level of Care
*
VP
Level of Care
X
*
I
I or II
VP
0/P
X or
X
X
VP
0/P
X
I or II
X or
I or II
X
symp1oms
t
Encounter
Level of Care
Altered Mental
Status
Chest pain
1
Dyspnea
1
Cough
1
Abdominal pain 1
Rash
1
Back pain
1
Joint
1
pain/swelling
Headache
1
Dysuria
1
Fever
1
* Level of Care:
I = Perform under supervision
0/P
I
Pulmonary Medicine
Encounter
Required
Minimum
Obstructive
3
Airway
Diseases
Pneumonia
1
Required
Minimum
1
0/P
Level of Care
*
*
VP
I or II
X
II
II
II
I or II
II
I or II
I or II
X
X or
X or
X or
X or
X or
X or
I or II
I or II
II
X or
X or
X
0/P
X
X
X
X
X
X
X
X
II = Assist with evaluation/treatment
III = Observe
Page/7
If the student does not meet minimum requirement of number s and kinds of patients,
they will receive an incomplete in clinical encounter s (I-CE) and the means to complete
this r equirement will be at the discretion of the clerkship director .
THE STUDENT IS REQUIRED TO LET THE CLERKSHIP COORDINATOR KNOW AT
LEAST 2 WEEKS PRIOR TO THE END OF THE ROTATION IF THEY HAVE NOT
MET THE MINIMUM PATIENT ENCOUNTERS.
Complete list of procedures for clinical clerks by December of the
third year - those marked in red are required w hile on 1M
1) Venipuncture (5)
2) Intravenous catheter placement (5) (complete on I.M.)
3) Arterial blood sample for blood gas determination (observe) (complete on I.M.)
4) Injection
i) Intradermal
ii) Subcutaneous
iii) Intramuscular
5) Incision and drainage of superficial abscess
6) Heel and finger stick blood sample
7) Local anesthetic injection
8) ACLS certification (complete on I.M.)
9) Skin biopsy
i) Punch
ii) Shave
iii) Fusiform
10) Simple skin closure
11) Suture removal
12) Intradermal skin test with interpretation
13) Cerumen removal
14) Eye irrigation, foreign body removal and fluorescein staining
15) Nasogastric tube placement
16) Endotracheal intubation demonstrated on a model
17) Bladder catheterization and foley catheter placement
18) Joint aspiration/injection
19) Lumbar puncture
20) Arterial line placement
Page j8
STUDENT EXPECTATIONS- CLASS OF 2016
1.
You will see your patients before rounds and inform the intern of any developments.
2.
During rounds you are expected to collect the charts as the team rounds.
3.
You will be expected to present your patient at rounds.
4.
You will be expected to pick up at least 3 new patients during call day and present them
the next morning at ward rounds.
5.
You are still expected to see your old patients that day.
6.
You should go to every admission - this is for your benefit and to help the team.
7.
Your goal of the rotation is to learn physical signs and patient symptoms with correlating
disease state and development of differential diagnosis - the more you do - the more you
learn. Internal Medicine is the foundation for all medicine and it is what is mostly tested
on your future boards - Step 2 and Step 3.
8.
Typical (non-call) day - Come in early. See your patients, write your notes and round
with your team. Please print out a team list (the interns will show you how). Be prepared
to present them. Know labs, radiological results and medication list. You should know
how to write a SOAP note. Make sure the Team Leader goes over your SOAP notes the
first week. You can write orders and have the intern co-sign them. Go to lecture when
scheduled.
9.
Typical (call) day - Come in early. Let both your intern and resident know you are here.
If they don't know you are here, they won' t call you with an admission. See your old
patients and write notes. Go to lectures and let the team know when you are gone and
when you come back. No overnight call. Leave at 11:00pm.
10.
On Saturday and Sunday, come in at 8:00AM.
11.
During the night float time - You will make contact with your team's intern and report for
duty the morning of the night float shift. You will round with the team, and then be
excused at Noon to return and begin the night float shift at 8:00pm. Be sure to make
contact with your intern upon returning at 8:00pm. You will work with the intern
through the night and be dismissed the following day at Noon. You will sign out your
patient to the student(s) who will be assuming the care of your patient the following day.
You will miss the student lectures on the night of call and on the following day. There
will be a total of two (2) night float shift nights during your ward months. The earlier
you do them the better so as not to interfere with your studying. ONLY 1 STUDENT
PER TEAM ALLOWED ON NIGHT FLOAT AT A TIME. It is suggested you do
them the first four weeks of your eight week inpatient experience.
Page 19
The monthly Inpatient Ward Evaluations, daily Outpatient Clinic Evaluations, weekly Student
Morning Report Presentation Evaluations and multi-weekly Student Teaching Rounds lecture
evaluations are completed within the MUSM One 45 computer software program. The mid-term
and final evaluations are completed BOTH on paper and in the ONE45 computer system.
The forms provided in this manual reflect the items being evaluated.
ALTERNATE INSTRUCTIONS OF HOW TO COMPLETE STUDENT
TEACHING ROUNDS EVALUATION FORMS IN ONE45
1.
Log in to ONE45
2.
Go to "To Dos"
3.
Click on Choose a New Form To Complete
4.
Select form: Student Teaching Rounds Lecture
5.
Select speaker's name
6.
Select date of lecture
7.
Click submit then you will see please confirm, the click submit again
8.
Type in the speaker's name on the form
9.
Type in the speaker's topic on the form
10.
Select the date ofthe lecture from the drop down box
11.
Complete the evaluation and include comments
12.
Click submit
As this form will remain in your ONE45 inbox to complete after each
lecture, please be sure to complete it after the end of the lecture.
Page 110
Internal Medicine Clerkship Rotation
Student Evaluation of Faculty/Resident/Intern
Faculty/Resident/Intern/Backup Name:
Evaluator's Name:
Rotation Period:
<<Faculty_Name»
«Student Name»
<<BegDate» to <<EndDate»
Please evaluate your faculty/resident/intern's performance during this rotation utilizing the
following scale:
4 = Outstanding
3 = Above Average
2 = Average
1 = Below Average 0 =Unacceptable
All individual responses will be kept CONFIDENTIAL. Composite summary data will be
provided to faculty in an ANONYMOUS format. Place a check mark in the appropriate box for
each area:
0
1
2
3
4
Unacceptable
Below
Average
Average
Above
Average
Outstanding
Medical Knowledge
Professional Attitude
Teaching Skills
A vail ability to you during rotation
Value of teaching sessions on rounds
Comments or suggestions for improvement:
Please return NO LATER THAN END OF MONTH to Clerkship Coordinator.
THANK YOU!
UPDATED: 6/28/2012
Page jll
STUDENT MORNING REPORT PRESENTATION EVALUATION
Student:
Date:
Title ofPresentation:
Unacceptable
Below Avg
Avg
1
0
2
Evaluator:
AboveAvg
3
Outstanding
4
Outline and organization
Preparation was adequate
Basic science materials
incorporated
Evidence-based and/or well
referenced literature reviewed
Demeanor and presentation
was professional
Use of technology and/or
audiovisual media
Response to questions
Overall this was a good
educational experience
Comments and suggestions for improvement:
Evaluators Signature
PLEASE RETURN TO CLERKSHIP COORDINATOR
DEPARTMENT OF INTERNAL MEDICINE
707 PINE STREET- MCCG HOSPITAL BOX #74
MACON, GEORGIA 31201
Page /12
Internal Medicine Clerkship Rotation
Student Teaching Rounds Faculty Weekly Evaluation
Faculty Name:
Evaluator:
Topic:
Date:
Please evaluate the attending listed above that lectured during this rotation utilizing the following
scale:
4 = Outstanding 3 = Above Average
2 =Average
I = Below Average
0 = Unacceptable
All individual responses will be kept CONFIDENTIAL. Composite summary data will be
provided to faculty in an ANONYMOUS format. Place a check mark in the appropriate box for
each area:
2
3
4
Average
Above Average
Outstanding
0
Unacceptable
Below average
Attitude towards teaching
D
D
D
D
D
Medical knowledge
D
D
D
D
D
Professionalism
D
D
D
D
D
Overall quality of session
D
D
D
D
D
Value of teaching sessions
D
D
D
D
D
Comments or suggestions for improvement:
Please return form to Clerkship Coordinator's mailbox before you leave today. THANK YOU!!!
UPDATED: 6/ 11/2007
Page /13
Mercer SOM
Yr3 Clerkship
Evaluated By: evaluator's name
Evaluating
:person (role} or moment's name (if applicable}
:start date to end date
Dates
---
--------
-
-
I
- - - - ___ _l _______ _
* indicates a mandatory response
* Have you ever had a therapeutic relationship with this student? (Yes or No)
'
I
* Service
Internal Medicine Evaluation of Students-Macon
n/a
Fails to meet
m inimal
expectations for
student at this
level of training
Meets minimal
expectations
for student at
this level of
training
Meets
expectations
for student
at this level
of training
Exceeds
expectations
for student
at this level
of training
"' 1. Data Gathering-History: Obtains precise. logical,
thorough, reliable history directed toward patient's
problems in a considerate, organized, and systematic way.
0
0
0
0
0
"' 2. Interviewing Skills: Possesses the interpersonal
skills important for both communicating information and
obtaining information from patients.
0
0
0
0
0
* 3. Data Gathering-Physical Exam: Conducts a
complete, accurate. logically-sequenced physical exam
directed toward patients problems. minimizing patient
dis comfort.
0
0
0
0
0
* 4. Basic Science Knowledge: Possesses
multidisciplinary knowledge and is able to correlate with
the clinical problem or disease.
0
0
0
0
0
* 5. Medical Knowledge: Possesses an extensive fund of
clinical information that is evident without prior
preparation.
0
0
0
0
0
" 6. Clinical Reasoning Skills: Understands physiologic
meaning of patient findings and interrelates them logically
to develop a differential diagnosis; identifies all major
problems and prioritizes workup appropriately.
0
0
0
0
0
* 7. Humanism: Demonstrates reliability, integrity,
empathy, compass ion, and respect for patients with
primary concern for patient's welfare.
0
0
0
0
0
* 8. Presentation Skills: 'v\ell organized, concise and
complete.
0
0
0
0
0
* 9. Teachability: Appears interested, receives
constructive criticism well
0
0
0
0
0
0
0
0
0
0
* 10. Punctuality: On time, has notes done
0
* 11. Availability: Availability on-call
0
0
0
* 12. Personal Appearance: Clean, neat, well groomed,
wears badge and white coat
0
0
0
0
0
0
" 13. Systems Based Practice: Does the student
understand how to help patients with limited financial
resources obtain their medications at dis charge?
0
0
0
0
0
* 14. Does the student accept the feedback and coaching
they receive willingly and incorporate this into their
practice?
0
0
0
0
0
* Formative Comments (Coaching)
Page 1
Summative Comments (Contribute to grade and Dean's lette r )
* Knowledge :
* Attitude:
* Skills :
* Profess ion a lis m :
Would you like to have this student in our residency program?
0 No
0 Yes
THANK YOU FOR TAKING THE TIME TO PROVIDE THE INFORMATION NEEDED TO GIVE AN ACCURATE GRADE TO OUR STUDENTS.
The following will be displayed on forms where feedback is enabled ...
(for the evaluator to answer. .. )
* Did you have an opportunity to meet with this trainee to discuss their performance?
QYes
0No
(for the evaluee to answer. .. )
* Did you have an opportunity to discuss your performance with your preceptor/supervisor?
QYes
0No
Page 2
Internal Medicine 3RD Year Clerkship
MID-TERM STUDENT EVALUATION
Class of 2016
Student: _ _ _ _ _ _ _ __
Clerkship Rotation: Internal Medicine
Clerkship Dates: Beginning: _ _ __
Midterm date: _ _ _ __
Ending:__
Rotation:
Extra 2 points at midterm: __Yes __ No
Absences: _ __
Patient Encounters: - STR evaluations completed _ _ __
Reflective Writing Entries: _ __
H&P's:- - - - -
A.
Overall assessment of student's performance:
B.
Narrative describing student's performance:
a. Knowledge:
b. Skills:
c. Attitude:
d. Professionalism including STR attendance :
C.
CLERKSHIP DIRECTOR'S COMMENTS:
STUDENT'S COMMENTS:
(Use other side if needed)
Student: _ _ _ _ _ _ _ _ _ __
Clerkship Director:
(Rossana Carter, MD)
Signature
Signature
16
INTERNAL MEDICINE FINAL EVALUATION OF CLERKSHIP
1. Were your educational goals met on your IM clerkship? If not, please explain.
Yes
No
2. Please describe the quality of teaching by the faculty and residents. If overt
weaknesses notice, please describe.
3. Were you given a mid-term evaluation?
- - - Yes
- - - No
4. Did the faculty and residents give you feedback on your performance
throughout the rotation?
---
Yes
- - - No
If so, was it helpful?
---
Yes
- - - No
5. What could the department of IM have done differently to make your educational
experience more productive?
6. List 5 strengths noted in the department.
7. List 5 weaknesses noted in the department.
17
Performance/Evaluation- Appeals Committee on Students
Mercer University School of Medicine's grading system is a pass/fail grading system for
the Third Year Clerkship rotations. This means that you will not be compared to your
colleagues until the final Dean letter. This letter will have a bar graph, which will
represent the distribution of your class in each clerkship.
The total percentage that can be obtained in IM is 100, so your final numerical grade is
the percentage you achieved out of 100. The minimal percentage needed to pass is
65. If for some reason you do not agree with your calculated total score, you may file a
complaint to the appeals committee. Your appeal must be submitted in writing one week
prior to the meeting day so members of the committee will have time to prepare to hear
your case. They will review your file in detail and notify you with their final decision.
Remediation Policy/Effect of failure to meet evaluation standards
* All remediation must be completed within 6 months of completion of the Yd year
curriculum. *
If student fails to obtain a total of 65% during the rotation, the student must remediate for
one month.
If a medical student fails the shelf test on the first attempt, they will be given an
incomplete for the rotation until that time that the shelf test is retaken. If they pass the
shelf on the second attempt, they will pass the rotation. If however, they should fail the
repeat shelf, they will receive a failure grade for the rotation and they will be required to
retake the rotation in its entirety and will be assigned to a faculty member for close
monitoring.
If the student should fail the ward or clinical experience, but pass the shelf test, they will
be given an incomplete until which time they remediate one month of clinical wards with
a specified attending. The student will be monitored closely and given as much
guidance as needed. They will take call, keep a logbook, attend conferences, and take
the shelf test. If they perform in a satisfactory fashion, they will receive a final grade of
satisfactory. If they should fail the one-month remediation , earning less than a
cumulative score of 3.0, they will be required to repeat the internal medicine clerkship in
its entirety. The student should receive an average of 3.0 on their cumulative clinical
performance.
·
·
·
If student fails the shelf and clinical, the student fails the clerkship and must
repeat the entire Internal Medicine rotation.
18
Policy on Attendance/Absences
Procedure for reporting/requesting absences
Effect of failure to meet attendance requirements
Policy:
A 100% attendance is expected by all students on rotation. You are expected to participate in all
scheduled activities. As clinical and educational activities arise, other activities may be scheduled. You
should keep the hours from 8:00am to 5:00pm available for clinical, educational, and academic activities
even if nothing is scheduled. Significant absences or tardiness constitute a lack of professionalism and
will be dealt with as such.
The Clerkship Director may request a letter from the student's physician if the student misses more than
2 (two) days or at the clerkship director's discretion.
Generally, excused absences are granted for sickness, death in the family, or a Mercer sanctioned
educational meeting with prior approval.
All unexcused absences will require remediation at the Clerkship Director's discretion.
*Making up call: If for any reason you will miss a call day - you will be required to make that day up.
No switching call days between teams. You must stay on your team and remain on Q4. The day that
the call day will be made up will be at the direction and discretion of the Clerkship Director.
Procedure for reporting/requesting absences:
An advanced written request should be submitted to the Clerkship Director via the Clerkship
Coordinator for all absences. The written request can be in the form of an e-mail. All absences should
occur with full knowledge and permission of the Clerkship Director via the Clerkship Coordinator and
Attending Physician of your team. If you are working on your outpatient weeks, absences should occur
with full knowledge and permission of the Clerkship Coordinator and Resident/Attending Physician you
are assigned to work with during that time.
If you are unexpectedly ill or have an emergency that requires you to be absent, you MUST notify the
clerkship coordinator and the attending and/or resident of the service that you are currently working on.
*All absences during the rotation will be reported to Lisa Killingsworth, Clinical Medical Education
Coordinator at the end of each rotation. *
Effect of failure to meet attendance requirements:
If a student misses 4 (four) or more days of the rotation due to excused or unexcused absences, an
incomplete for the rotation will be given and an appropriate remediation experience will be required.
The time of the remediation will be at Christmas Break or before the beginning of the Fourth Year or at
the clerkship director's discretion. If the students misses 5 (five) days or more, a one-week remediation
will be mandatory.
19
SERVICE RESPONSIBILITIES
***Please note when selecting your top 3 schedule and top 3 subspecialty preferences prior to beginning
Internal Medicine, be sure to send your email reply as soon as possible. The schedule is created on a first
come first serve basis with the schedule preferences taken into consideration and NO CHANGING of the
rotation schedule is allowed once it is set at the beginning of the 12-week rotation unless deemed
necessary by the Clerkship Director. ***
INPATIENT RESPONSIBILITIES - Inpatient Service (8 weeks - two 4 week blocks)
Every 4th night call, Report at 8:00am until I 1:00pm. Call ends at I 1:00pm
You are expected to arrive early enough to evaluate your patients prior to work rounds or
conferences on days that you are not on call. On Saturdays and Sundays if you are on call
you are to report at 8:00am.
Day
Mon
Tue
Wed
Thu
Fri
Sat
Sun
Time
Duty
9:00am
11 :30am
I 2:00pm
1:00pm
9:00am
11:30am
I 2:30pm
8:00am
9:00am
I 1:30am
I 2:30pm
9:00am
11:30am
I 2:30pm
8:00am or I 1:30am
9:00am
8:00am
8:00am
Work Rounds
Ward morning report after rounds
Tumor Conference (optional)
History & Physical and DDX session or
Neurology Rounds
Work Rounds
Ward morning report after rounds
Student Teaching Rounds Lecture
Grand Rounds
Work Rounds
Ward morning report after rounds
Student Teaching Rounds Lecture
Work Rounds
Ward morning report after rounds
Student Teaching Rounds Lecture
Outpatient Student Morning Report
Work Rounds
Report for call
Report for call
While on inpatient weeks the student will have two night float shift experiences. When the team is on
call, the student will take two shifts during a four week period, beginning at 8pm to 12pm the following
day. Formal checkouts between the student who admitted the patient and the student assuming care of
the patient the following morning will be performed. Be reminded you must report to work the morning
of the night float shift and round with your team. You will be excused at Noon to return to work at 8pm
to begin the night float shift. ONLY 1 STUDENT PER TEAM ALLOWED ON NIGHT FLOAT
AT A TIME.
OU SHOULD ALWAYS BE AVAILABLE BY PAGER.
LEASE KEEP YOUR PAGER ON AT ALL TIMES!
20
4-WEEKS INPATIENT in SANDERSVILLE, GEORGIA
WASHINGTON COUNTY INTERNAL MEDICINE
501 SPARTA ROAD, SUITE F
SANDERSVILLE, GA 31082
CONTACT MRS. MUNDY 1\.T LEAST ONE MONTH PRIOR TO YOUR ARRIVAL!
Mrs. Erin Mundy, MPA
Cell: 678-232-3759 Fax: 706-721-8508 Email: [email protected]
Statewide AHEC Network Program Office * Georgia Regents University * Room AA 1057
Augusta, Georgia 30912
Description:
Students will arrive in Sandersville, GA on the Monday afternoon of week 5 of their Internal Medicine
rotation. Electing to participate in Sandersville for four weeks will count toward four weeks of inpatient
time for the Internal Medicine rotation. While rotating in Sandersville, the student will be expected to
view the live weekly Student Teaching Rounds lecture via Skype. Equipment has been provided for the
student to view each lecture. The students will be excused from their clinical duties during lecture time.
There will be no overnight call while in Sandersville.
Housing, food, badges and key pick up information:
Contact Mrs. Erin Mundy at least one month prior to your arrival. Mrs. Mundy will schedule your
Sandersville orientation session with a community representative and the Area Health Education Center
representative the first week you are in the city. She will also issue the student's key for housing.
Orientation of Washington County Internal Medicine:
Dr. Jean Sumner and/or Dr. Kim Kitchens will provide you with an orientation to the facility.
Contact Mrs. Erin Mundy to arrange the orientation schedule.
Directions to the hospital and housing are provided within the hyperlink below:
Click here for directions to student housing. (500 North Harris St., Sandersville, GA 31 082)
Click here for directions to Washington County Internal Medicine
501 Sparta Road Suite F
Sandersville, Georgia 31082
Click here for directions to Washington County Regional Medical Center.
I Students are only allowed to go to Sandersville during the second four week block of the rotation.
21
c
Day
Man
Please see below for a table of daily events while you are on your 4-weeks of outpatient duties
(The legend of abbreviations is below the table)
Time
WT Anderson
Health Clinic
8:00am
8:30am
1:00pm
or
*2:00pm
Report
w/assigned
physician
H & P and DDX
session or
*physical findings
rounds w/Dr. T.
Hope
1:30pm
Tues
7:30am
8:00am
12:30pm
1:30pm
Wed
8:00am
9:00am
1:30pm
Thurs
12:30pm
1:30pm
Fri
Bam or
11 :30am
9:00am
Sat
8:00am
Sun
8:00am
Nephro Clinic
(2wks)
STR Lecture
Report
w/assigned
physician
GR@ Med Ed
Report
w/assigned
p_hysician
Report
w/assigned
physician
Report
w/assigned
physician
STR Lecture
Report
w/assigned
physician
SMR
Report
w/assigned
physician
Report for call on
weekend prewards
Report for call on
weekend prewards
ID Clinic
(2wks)
Neuro Clinic
(2wks)
Endo Clinic
(2wks)
Report to resident
on Cardiology
Report to Dr.
Nwaohiri
Report to Dr.
Katner
Report to
Neurology
Assoc. office
Report to Dr.
Kohse
H & P and DDX
session or
*physical findings
rounds w/Dr. T.
Hope
Cardiology Clinic
@WTA
H & P and DDX
session or
*physical findings
rounds w/Dr. T.
Hope
H & P and
DDX session
or *physical
findings rounds
w/Dr. T. Hope
H & P and
DDX session
or *physical
findings rounds
w/Dr. T. Hope
H & P and
DDX session
or *physical
findings rounds
w/Dr. T. Hope
Report to resident
on Cardiology
STR Lecture
Report to Dr.
Nwaohiri
STR Lecture
STR Lecture
Neurology
Associates
STR Lecture
Report to Dr.
Kohse
STR Lecture
GR@ Med Ed
Report to resident
on Cardiology
GR@ Med Ed
Report to Dr.
Nwaohiri
GR@ Med Ed
Report to Dr.
Katner
GR@ Med Ed
Neurology
Associates
GR@ Med Ed
Report to Dr.
Kohse
Report to resident
on Cardiology
Report to Dr.
Nwaohiri
Report to Dr.
Katner
Neurology
Associates
Report to Dr.
Kohse
The Hope Ctr.
8:00am
8:30am
Cardio Clinic
(2wks)
The Hope Ctr.
STR Lecture
STR Lecture
STR Lecture
STR Lecture
STR Lecture
SMR
SMR
SMR
SMR
SMR
Report to resident
on Cardiology
Report to Dr.
Nwaohiri
22
Report to Dr.
Katner
Neurology
Associates
Report to Dr.
Kohse
Legend of Abbreviations used in table of daily events while on 4-weeks of outpatient duties
STR Lecture = Student Teaching Rounds Lecture
ID Clinic = Infectious Disease Clinic
GR = Grand Rounds at 790 First St. - The Medical Education Building
SMR = Student Morning Report
* Neuro rounds with Dr. Hope will begin after required lectures. You will meet outside ofthe
student lounge in the lobby of MCCG
OUTPATIEN T RESPONSIBILITIES
Outpatient Service (4 weeks) - No call during this time
•
No call Fri, Sat, Sun prior to beginning clinic week
•
•
Take call Fri, Sat, Sun of clinic week before you begin on inpatient wards
All schedule changes must be re orted to Clerkshi Coordinator!
2 weeks - W.T. Anderson Health Center Clinic - 764 Pine Street, 3rd floor
While on two weeks of WTA Health Center clinic, you are expected to arrive at
the WT Anderson Health Center by 8:30AM on the 3rd (third) floor.
Next choose 1 of the 4 subspecialty options below:
2 weeks - Nephrology Clinic; contact Beth Weires, RN, 478-301-4145 to determine
which Nephrologist you will be working with in the clinic that week.
2 weeks- Infectious Disease Clinic; contact Dr. Harold Katner, 478-749-5550 to
determine meeting location and time. Contact Dr. Ritu Kumar, 478-749-4009 if Dr.
Katner is away to determine meeting location and time.
2 weeks - Cardiology Clinic; contact Dr. Ahmed Shah @ 478-227-4248 to inform him
you are the student for the next two weeks on Cardiology. You will be working with
the resident currently on Cardiology. Contact the Clerkship Coordinator to find out
the name of the current resident.
2 weeks - Neurology Clinic: contact Starr Brown or Bridget Mathis, 478-743-9123 to
determine meeting location and time. You will be working with Dr. Thomas Hope or
Dr. John Spiegel.
2 weeks - Endocrinology Clinic: contact Dr. Larry Kohse, 478-461-3822 to determine
meeting location and time.
ANDERSON HEALTH CENTER CLINIC- (2 WEEKS)
You are expected to be PUNCTUAL and show-up to Anderson Health Center clinic NO later than
8:30AM. Each Tuesday you are to arrive at The Hope Center, which begins at 7:30AM. (Please see
directions to The Hope Center Clinic provided below).
•
Please refer to the Outpatient Clinic Schedule to confirm your clinic assignments.
•
You are NOT to work directly with interns during July to December.
23
•
•
•
•
If there is a new patient to the clinic, the nursing staff will notify you and have the patient in a
room ready for you.
You are to perform a complete History and Physical and present the case to the clinic attending
or upper level resident involved in the case.
If no new patient is present, you will be expected to see follow-up visits and do focused H&P's
and present to the upper level resident involved in the case or the clinic attending.
You are to attend all Student Teaching Rounds Lectures.
*DO NOT FORGET TO LOG PATIENT ENCOUNTERS ON MUSM ONE 45 SOFTWARE*
INFECTIOUS DISEASE CLINIC- Dr. Harold Katner's pager- 478-749-5550
Students will attend The Hope Center during their outpatient clinic weeks on Tuesday
mornings and also during their two weeks ofiD SUBPECIALTY clinic seeing patients with
Dr. Harold Katner, Dr. Jeff Stephens or Dr. Ritu Kumar. You are to page Dr. Harold Katner
at least two weeks prior to beginning clinic to receive your meeting time and location
information.
Directions to The Hope Center from 707 Pine Street for ID Clinic
Hope Center
135 Macon West Drive
Macon, GA 31210
(478) 405-7220
1.
Start out going southeast on Pine St. toward First Street.
2.
Turn Right onto First Street.
3.
First Street becomes Telfair Street.
4.
Tum Right onto Little Richard Penniman Boulevard.
5.
Little Richard Penniman Blvd. becomes Mercer University Dr.
6.
Continue on Mercer University Dr. all the way to 135 Macon West Dr.
(you will tum Right at the comer where the GA School Supply building is)
7.
The Hope Center is located on the left hand side. It is the 4th bldg.
Estimated driving time: 15 minutes
CARDIOLOGY SUBSPECIALTY TWO WEEKS
Students will attend cardiology clinic for two weeks if selected. YOU ARE REQUIRED TO
WEAR SCRUBS DURING THIS WEEK! Please contact Dr. Ahmed Shah at 478-227-4248 if
you have any questions; female students please notify him IMMEDIATELY if you are pregnant.
Please note during holiday weeks minimal patient exposure may occur. While on two weeks of
Cardiology clinic, you will report to the resident who is working on Cardiology for the month.
Contact the Clerkship Coordinator at least two weeks prior to beginning rotation to find out the
name and pager number of the assigned resident.
24
NEPHROLOGY SUBSPECIALTY TWO WEEKS
Students will attend Nephrology clinic for two weeks if selected. Please contact Mrs. Beth Weires,
RN at 478-301-4145 at least two weeks prior to beginning rotation to determine meeting time and
location.
ENDOCRINOLOGY SUBSPECIALTY TWO WEEKS
Students will attend Endocrinology clinic for two weeks if selected. Please contact Dr. Larry Kohse,
at 4 78-461-3 822 or [email protected] at least two weeks prior to beginning rotation to determine
meeting time and location.
NEUROLOGY SUBSPECIALTY TWO WEEKS
Students will attend Neurology clinic at 3 89 Mulberry Street, Suite 200, for two weeks if selected.
Please contact at least two weeks prior to beginning rotation either Mrs. Starr Brown, medical
assistant for Dr. Hope or Mrs. Bridget Mathis, nurse for Dr. Spiegel at 478-743-9123 to determine
meeting time. Please see below for directions.
Directions to Neurology Associates from 707 Pine Street for Neuro Clinic
Neurology Associates
389 Mulberry Street, Suite 200
Macon, Georgia 31201
478-743-9123
1.
2.
3.
4.
5.
Start out going southeast on Pine Street toward First Street
Take the 1st left onto First Street
Turn right onto Poplar Street
Turn left onto Martin Luther King Jr. Blvd.
Turn left onto Mulberry Street
NEUROLOGY ASSOCIATES will be on the right.
ESTIMATED DRIVING TIME: 5 MINUTES
__
OU SHOULD ALWAYS BE AVAILABLE BY PAGER......__
.....,
PLEASE KEEP YOUR PAGER ON AND WITH YOU AT ALL TIMES!
25
MCCG Intranet
Please note: Use of the MCCG Intranet will allow you to have access and view the
Internal Medicine Call Schedule 1, Core Curriculum Conference Schedule~, EKG
files for Core Curriculum Conference ~, Grand Rounds Lecture Schedule ~ and
other educational activities.
Ask the intern or upper level resident on your inpatient team for instructions on
how to log in to and access the MCCG Intranet .
.1
http: //intranet/medicaleducation/IM/oncall.asp
~ http:
~ http:
//intranet/medicaleducation/IM/teaching-conf.asp
//intranet/medicaleducation/IM/online-presentations.asp
~ http:
//intranet/medicaleducation/IM/grand-rounds.asp
Mercer University Blackboard
Mercer University Blackboard page has links that you may access various
teaching files throughout the rotation under the Savannah Campus folder. To
access blackboard go online to: https: //bb-mercer.blackboard.com/ and enter
your username and password. Contact the Clerkship Coordinator if you have any
questions.
26
History and Physicals/Work Ups
Call days- You are expected to work up 3-4 new patients on call day. You will still need to see other patients
even if you do not fully work them up with the team. Write ups should be between 3-4 typed pages, or 4-6
handwritten pages and must include a chief complaint, history of present illness, PMH, PSH, Medication, FH, SH,
ROS, PE, Labs, Assessment and Plan. H&Ps must be turned into the Clerkship Coordinator within 72 hours (3
days) of completion. They will be distributed to the attending physician for review. The attending physician
must review them with you. A typed copy of the H&P should follow the style using the template below. This is
only a guide. See the appendix for appropriate workup. Example of format is below.
STUDENT FIRST AND LAST NAME
Internal Medicine Team: A, B, CorD
Attending Physician: ~----
H&P # _
Page _ of _
(This information should he provided on each typed page)
Pt Identifiers: Last name, First name
DOB: mm/dd/yyyy
Date & Time of Admission: mm/dd/yyyy, -1800h
CC:
HPI:
PMH:
PSH:
MEDS:
ALLERGIES:
FH:
SH:
ROS:
Gen:
Derm:
Head:
Eyes:
Ears:
Nose:
Throat:
CV:
Pulm:
GI:
GU:
MS:
Neuro:
Heme:
En do:
Psych:
27
MRN: 098xxxxxx
PE: Vital Signs T _
P_
R_ _ BP _ /_ _ 02 Sat _ _ , BMI _ _
Gen:
Head:
Face:
Eyes:
Ears:
Nose:
Neck:
Mouth:
Heart:
Resp :
Abdomen:
GU:
Neuro:
Skin:
Extremities:
OLD LABS:
LAB DATA:
AlP
1.
•
DDx:
•
DDx:
2.
STUDENT NAME, MS III
Beeper xxxx
28
Record Keeping
SOAP Notes should be written on each patient daily and include patient information that
occurred within the past 24 hours. SOAP note style is appropriate with current labs and vitals.
A total of (4) four SOAP notes must be submitted to the attending for review & credit.
Presentations
Students should be prepared to present their patients each morning on rounds. An effort should
be made to make your presentation organized and without the use of notes. (This will take time
so personal notes are acceptable early on in rotation). Try to limit presentation to 2-3 minutes.
Always give minimal review of admitting information- i.e., Patient is 65yo F admitted for
CHF and to date we have diuresed 15 lbs.
Procedures
Students are welcome to perform procedures with residents or attending. Be sure to document
the procedures on your log within ONE45.
Other Responsibilities
• Report to all code blues when your team is on call.
• Assist residents in accumulation of data, labs, old records
• You are NOT responsible for carrying more than 3-4 patients.
• You are to act professionally AT ALL TIMES (Lab coats to be worn at all times).
• You are to work with patients in a respectful, compassionate, empathetic manner.
• You are expected to be PUNCTUAL and DEPENDABLE.
• You are to prepare and participate in ALL educational opportunities.
• You are expected to attend all conferences UNLESS you are post call. Particularly
attend student morning report out of respect for your peers.
• You are not to text during lectures!
• You are expected to KEEP A LOG OF ALL PATIENTS that you have
ACTIVELY followed. DO NOT FORGET TO DOCUMENT PROCEDURES!
PROFESSIONALISM
• It is paramount that the highest level of professional conduct be maintained at all
times.
• BEWARE of idle talk about cases up on the wards, conference rooms, elevators,
cafeteria, etc.
• Pages/beeps should be returned promptly and courteously.
• You are not to text or use cell phone in any manner during any of the lectures!
• Lack of professionalism is a failable offense.
KNOWLEDGE BASE
• Reading is fundamental to your learning. It is advised that you read on ALL of your
clinical encounters in addition to CORE readings.
•
Work on Differential Diagnoses. This supports what you have been reading.
29
Clarification of Medical Student Duty I Rules for the Third Year Clerkships
Mercer University School of Medicine
80 Hour week rule: Students will work no more than 80 hours a week averaged over a four week
block. This begins on the first day of the rotation and starts again on the first Monday of the next four
weeks. Students will work no more than 110% (88 hours) in any one week.
24 Hour Rule: Saturday call makes it impossible to guarantee 24 hours off every week. Students
should have four 24-hour periods off every 4 weeks and not go more than 2 consecutive weeks without
24 hours off.
30 Hour Rule: Students should not be "on call" or involved in in-patient care activities for more than
30 consecutive hours. Significant, group educational activities may take place beyond the 30 hours but
not for more than 36 total hours.
Yo u will be keeping track of this on your weekly work hour form. Be sure to make yourself a
photocopy of the weekly work hour form before turning it in each week.
REMINDER
ALL WEEKLY HOURS LOGS MUST BE TURNED IN BY THEDAY OF
YOUR LAST STUDENT TEACHING ROUNDS LECTURE SESSION!
30
STUDENT TEACIDNG ROUNDS LECTURE TOPICS
Atherosclerotic Heart Disease
Heart Failure
Basic Arrhythmias
Hypertension & Lipids
How to be a successful clerk
Developing a differential diagnosis for
Chest Pain
Developing a differential diagnosis for
Shortness of Breath
Dermatology
Thyroid
Diabetes
Neurology
End of Life & Medical Futility
Death Certificates
Acute Kidney Injury/Renal Emergencies
Acid Base
Intra to Infectious Disease
HIV/AIDS & Antiretroviral agents
HIV
Antibiotics & ID Cases
Pneumonia
{Rheumatology)
RA, SLE, GOUT, CPPD, OA, OSTEOPOROSIS
Anemia
Deep Vein Thombosis
Pulmonology
Pulmonary Case Presentation
w/radiographic review
Gastroenterology
Biostatistics
Medical Jeopardy
31
THIRD YEAR CLERKSHIP REQUIRED
I Important Information I
+ 1-Student Morning Report
+ 8-H&P's
+ 2-Reflective Writing Entries
+ ACLS mandatory class
+ 4-SOAP notes
+ OSCE video session
+ 12 weekly work hour logs
+ 2-night float calls + Shelf Test
+ MUSM "One45" computerized system for patient log including procedures & evaluations
Stud ent
Morning
Report
Reflective
Writinli: entries
OSCE's
(wk 7 of rotation)
(wk 4 & wk 8)
Fridays
Rotation I
7/28/201 4- 10/17/201 4
Rotation II
10/20/2014 -1123/201 5
Rotation III
1126/201 5 - 4/17/201 5
Rotation IV
4/20/2015 -7/10/2015
8:00am or
!1:30am
8:00am or
11 :30am
8:00am or
11 :30am
8:00am or
11 :30am
H & P 's and
Book Return
*Due 2 wks
prior to end of
rotation
Shelf Test
Last day of
rotation
8/18/14; 9/15/14
9/8/14
10/2/14
10/17/2014
11/10114; 12/8/14
12/1/14
1/8/15
1/23/2015
2/16/15; 3116115
3/9/15
4/2/15
4117/2015
5/11/15; 6/8/15
6/1/15
6/25/15
7/10/2015
*If student on outpatient for first 4 weeks ofrotation, deadline is one week prior to end ofrotation
*
Student Morning Reports - Friday Mornings
Each student will be assigned to work with an attending physician to present a case. When
selecting a case for Student Morning Report, use an adult patient, no pediatric cases! Choose
a case from the patients you've been exposed to during your inpatient ward experience. The
student must give topic of their presentation to clerkship coordinator & attending physician at
least one week prior to their presentation as well as contact the attending the day before their
presentation. YOUR ATTENDANCE IS MANDATORY with the exception of being post call.
If you have any questions please see Clerkship Coordinator.
Time:
8:00a.m.- 9:00a.m.
Location:
Medical Education Building- 790 First St.
Or
Time:
11 :30am-12:30pm
Location:
Internal Medicine Building - 707 Pine St.
Observed Standardized patient Clinical Exam (OSCE) - Mid-Rotation
Students arrive at the Clinical Development & Assessment Center at the designated time on the
day of the OSCE video exercise. Enter the facility from the outside door which faces the
Engineering School. Students must wear their white coats during this exercise. The CDAC is
formerly Mercer Health Systems and is located across from the Engineering School. Any
questions please see Clerkship Director or call the CDAC at 478-301-4038.
H&P Sessions -Monday Afternoons - Total of 8 H&Ps are required
Clerkship Director or designee does evidence based teaching, physical diagnosis and H&P's.
Any questions please see Clerkship Director.
Time: 1:00pm-2:00pm
Location:
707 Pine Street in the classroom
32
Reflective Writing Project Entries -Total of 2 entries are required
The Reflective learning Cyde
_....-.---...
//:~~l.l~vlr:.~ne·~
w;~y$of behavin.g.
.
tnin.\Jni, ·and
~;:
r~el),~g~ \,
' ... "· :'_ ~- ~~-~~
·
•,
.~ .
• · · I\ commltfl!-i!llt to
'yo
; .', ch;~n~ine I• r" .
< pr<lc~ffe , . -'. '.·:
l _____ r
......
. ., . /
..._,_____....
Gibbs Model for Reflection
~J
Action Plan
tilt roll~ ~~lf1 will~
w Oot.d<J you cJo?
(
~
l
t
Conclusion .
'1'1/b«l ..,!~ Cl;l'\l&d 'f"U
lJ.:a~vo
......._,. _
-..J
---
.
done7
Learning is more than the accumulation of facts; it includes personal growth, interpersonal
interactions, communication and professionalism. As a third year student you will encounter
things you have never experienced before. This reflective writing project is a way to reflect on
your experience and to learn from it.
You will be required to type and submit two reflective writing entries to your designated
attending. Once submitted, your attending will review your entry and make suggestions for
improvement.
The work will be modified by the student and resubmitted. Your final feedback can be
provided in person or via e-mail. Examples of a topic to include on your reflective writing
entry are below:
33
•
•
•
•
•
•
•
•
The death of a patient.
A conflict with a peer.
A mistake you made.
An ethical dilemma.
A disagreement with an attending or a resident.
A patient that you particularly liked.
An encounter with a nurse.
Anything that affected you emotionally or that makes you reflect on what it means
to be a doctor.
INSTRUCTIONS HOW TO ACCESS PHYSICAL FINDINGS WEBSITE
A physical findings website has been developed for students, which contain a number of
physical findings & physical exam maneuvers. All of the information on the physical findings
website will be "fair game" for the fourth year exit exam. While on Internal Medicine, students
are responsible for learning the content of the material on the website. The website address is
provided below along with proper log in directions. Please see the Clerkship Director with any
questions.
The login for the physical findings website is as follows:
1.
Click INTERNAL MEDICINE PHYSICAL FINDINGS to access website
http://medicine.mercer.edu/Departments/Internal%20Medicine/clerk_int_intro/physicalfindings
2.
Username: Your MUID Number
3.
Password: Your date ofbirth in this format YYMMDD
34
INTERNAL MEDICINE THIRD YEAR CLERKSHIP SYLLABUS
Internal Medicine is a 12-week rotation (8 weeks Inpatient, 4 weeks Outpatient).
The clerkship is designed to give you increasing responsibility in patient care within the hospital wards
and outpatient clinics.
The overall goal of the clerkship is growing independence. The majority of your learning comes
through personal experience so, DO NOT BE A BYSTANDER. Your willingness to go out on a limb
and take risks is expected. We expect "Thinking Outside The Box."
Your evaluation will be based on the RIME method. Each step is a synthesis ofknowledge, skill, and
attitudes.
REPORTER: Can work professionally with patients and staff and accurately gather and clearly
communicate the clinical facts on your patient and with the proper terminology (this takes basic
knowledge of what is important, plus the skill and reliability to do it consistently).
INTERPRETER: At a basic level, you must identify and prioritize new problems as they arise. The
next step is to offer a differential diagnosis. Success is offering at least three reasonable possibilities
for new problems and giving your reasons. (You won't always have the "right" answer.) This step
takes growing knowledge, skill in selecting clinical facts and seeing yourself as part of the intellectual
process.
MANAGER: This step takes even more knowledge, and more confidence, plus the skill to select
among options with your own patient, to be "proactive" rather than simply "reactive." Generally, your
diagnostic plan should include three appropriate test options and your therapeutic plan should offer
three possible therapies. Always state your own preference (you don't have to be correct).
EDUCATOR: Ultimately, your ability to help patients means an openness to new knowledge and
depends on your skill in identifying questions that cannot be answered from textbooks. Are you able
to site the evidence that new therapies and tests are worthwhile?
35
MISSION STATEMENT FOR THE JUNIOR CLERKSIDPS
MERCER UNIVERSITY SCHOOL OF MEDICINE
Mission
The mission of the junior clerkships is to broadly prepare students for the practice of clinical medicine
by facilitating their acquisition of the knowledge, behaviors, skills, and attitudes necessary for the
compassionate and competent care of patients.
Vision
Our vision is to create lifelong learners who embody the stated values of MUSM (collaboration,
compassion, competence, excellence, integrity, respect and honesty, and service) and who have a
commitment to meeting the health care needs of Georgia.
Goals
Our goal is that students will be able to effectively evaluate a patient by performing an appropriate
history and physical that facilitates differential diagnosis and the developing of a treatment plan.
Our goal is to ensure students obtain the core knowledge considered necessary for the practice of
medicine.
Our goal is to socialize medical students into the best of the culture of medicine such that they develop
an enduring commitment to the care of patients.
36
GRADING GRID for INTERNAL MEDICINE
The total grade is a sum of four components:
2 - Reflective Writing Entry Project
10-Written History & Physicals and 4-SOAP notes
Ward Performance
ShelfTest
Reflective Writing Entry Project- 10%
10%
10%
40%
40%
100% or 104% ifbonus earned
(Submit both writing assignments)
Written History & Physical and SOAP notes- 10% (8 H&Ps; 4 SOAP notes)
Must Tum in 8 H&Ps and 4 SOAP notes -Each will be critiqued by the ward attending physicians.
The physician will look for improvement in documentation skills and broadening of assessment and
plan. This is a formative exercise. It is at the discretion of the director or the ward attending physician
if all or portions of the H&P need to be redone. Maximum credit is given if all 8 H&Ps and 4 SOAP
notes are turned in.
NO PARTIAL CREDIT WILL BE GIVEN!
Shelf Test- 40%
(Pass
= 59% or higher; Fail = 58% or lower)
Ward Performance - 40%
(Pass
=56% or higher; Fail =55% or lower)
•
Knowledge Base
This score assesses the following four areas:
•Communication Skills/Presentation Skills
•
•Attitude
Problem Solving Skills/DDX
The ward performance evaluations are converted to a numerical score. The actual grade is the
average sum of all scores. The maximum obtainable score in this area is 4.0 which will result
in a maximum of 40% in this area.
1. Students who are required to remediate any component of a clerkship (with the
exception of incomplete clinical encounters-ICE) may not do so during a subsequent
clerkship.
2. All remediation events must be completed within 8 weeks of the end of Year III.
Students will not be allowed to enter Year 4 until all remediation events are successfully
completed.
3. Students who fail to complete remediation within 8 weeks will be required to go before
theSAPC.
37
An additional 2 bonus points will be given if weekly work hour logs, procedures, numbers & kinds, student
teaching rounds lecture evaluations, and H&Ps are up to date at the mid-term of the rotation. To be eligible to
earn the extra two bonus points at mid-term, the following minimum requirement must be met:
• 4 weekly work hour logs to include weeks 1-4 of the rotation
• ~of the required procedures and numbers & kinds entered into MUSM One45 system
• Student Teaching Rounds Lecture evaluations in One45 from weeks 1-5 of rotation
• 1 H&P although 4 H&Ps would be desired
An additional 2 bonus points will be given if weekly work hour logs, procedures, numbers & kinds, student
teaching rounds lecture evaluations and H&Ps are complete by week 11 of the rotation. A total of 4 bonus points
can be earned. If any of these components are missing your grade may be withheld until completion of
missing component.
Minimum Score on Shelf Exam =59%
Each student will be given a grade of pass, fail, or incomplete at the end of the rotation.
PASS -Minimal level of Competency
In order to obtain a passing grade in Internal Medicine all evaluations must be satisfactory or better,
the shelf exam must be passed and a cumulative score must be equal to or greater than 65%.
The breakdown for final grades at the end of the year as per the Clerkship Committee and the
Curriculum Committee are as follows:
PASS
FAIL
Numerical Score in Dean's Letter
MINIMUM CUMULATIVE PERCENTAGE FOR
PASSING MEDICINE ROTATION IS 65
38
Weekly Work Hours/Procedure Log Form:- (Form shown on next page)
The weekly work hours/procedure log form shows your accountability and responsibility of your
medicine clerkship activities and procedures for the rotation. In the first section to the left you will see
the heading DATE/# HRS WORKED. Beside each day of the week, write the date along with the total
number of hours you worked on that day provided underneath the date.
In the middle section underneath the heading TIME OF DAY WORKED provide the hours you were
actually here, i.e., 8:00a.m.- 4:30p.m. If during this time you completed your night float call, have
the night float resident that you worked with to sign their name in the night float name box.
In the right side section write any procedures you performed on that day. Remember this information
must also be entered into the ONE45 computer system as well as on this procedure log form.
In the bottom section circle the correct box if you worked inpatient or outpatient and which team or
subspecialty you worked during that week. You must also total your own hours and provide your
signature as well as printed name in the box provided. Don't forget to circle the appropriate the week
number of the rotation. You must tum in at least one log sheet for each of the twelve weeks that you
are on the rotation. The Clerkship Director and Clerkship Coordinator will review your work.
Your signature shows you are attesting that the information you have submitted is true to the best of
your knowledge. It is suggested that you keep a photocopy of each weekly log form that you tum in
for your own records.
Please note: If your hours are not totaled or if you do not provide your signature and printed name at
the bottom of the form or if you do not circle the appropriate week number, the form will be returned
to you in order for you to complete each of these tasks.
*Students are required to enter all patient encounters into the MUSM "One45" software at the
medical school. The deadline to enter the information is the Saturday after the Shelf Exam.*
39
MERCER UNIVERSITY SCHOOL OF MEDICINE
Department of Internal Medicine Junior Medical Students
WEEKLY WORK HOURS/PROCEDURE LOG FORM
DATE/# HRS WORKED
PROCEDURE(S)PERFORMED
TIME OF DAY WORKED
MON
AM
Number of hours:
to
PM
Night float name if applicable:
DATE/# HRS WORKED
PROCEDURE(S)PERFORMED
TIME OF DAY WORKED
TUES
AM
Number of hours:
to
PM
Night float name if applicable:
DATE/# HRS WORKED
PROCEDURE(S)PERFORMED
TIME OF DAY WORKED
WED
AM
Number of hours:
PM
to
Night float name if applicable:
DATE/# HRS WORKED
PROCEDURE(S)PERFORMED
TIME OF DAY WORKED
THURS
AM
Number of hours
to
PM
Night float name if applicable:
PROCEDURE(S)PERFORMED
TIME OF DAY WORKED
DATE/# HRS WORKED
FRI
to
AM
PM
Night float name if applicable:
Number of hours:
DATE/# HRS WORKED
PROCEDURE(S)PERFORMED
TIME OF DAY WORKED
SAT
AM
Number of hours:
PM
to
Night float name if applicable:
PROCEDURE(S)PERFORMED
TIME OF DAY WORKED
DATE/# HRS WORKED
SUN
AM
to
PM
Night float name if applicable:
Number of hours:
Please circle the proper category for thi s week; Enter the grand total work hours; Student Signature REQUIRED
INPATIENT TEAM-
A
B
c
Outpt- Endo; Neuro; Cardio; Nephro; ID;
D
or Ambulatory
Student Signature reguired:
GRAND TOTAL HOURS FOR THE WEEK:
Print Student Name:
Please circle correct week#:
1
2
3
5
4
40
6
7
8
9
10
11
12
HOLIDAY SCHEDULE FOR BEING ON CALL
Students will be off beginning at 6pm the night before the holiday until 6am the moming after the
holiday.
Example:
Memorial Day (Monday)
Sunday @ 6pm the students are off and will return to work on Tuesday @ 6an1
CALL SCHEDULE AROUND OSCE'S and ACLS
On the day prior to OSCE's & ACLS if the student is on wards and on call, the student will leave at
6:00pm. After OSCE and ACLS students must report back to their team. Students will take call on the
night they retum to the team until11 :OOpm.
CALL SCHEDULE AT THE END OF THE ROTATION
If the student is working on wards during the last four (4) weeks of the rotation, the student's last day
of call is the Saturday prior to the end of the rotation. Your call will end at 6:00PM. Your patient
responsibilities will end on the Wednesday aftemoon of week 12 ofthe rotation after Core Conference.
MERCER UNIVERSITY SCHOOL OF MEDICINE HOLIDAYS
Labor Day
Mon. Sept. 1, 2014
Thanksgiving
Thurs. Nov. 27, 2014 & Fri. Nov. 28, 2014
Christmas Break
Sat. Dec. 20, 2014- Sun. Jan. 4, 2015
Martin Luther King, Jr. Day
Mon. Jan. 19, 2015
Good Friday
Memorial Day Holiday
Independence Day Holiday
Fri. Apr. 3, 2015
Mon. May 25,2015
Friday July 3, 2015
41
-MERCER UNIVERSITY SCHOOL of MEDICINEJohn A. Hudson, M.D., Internal Medicine Chairman (Interim)
Rossana Carter, M.D., Internal Medicine Clerkship Director
Thomas Hope, M.D., Internal Medicine Clerkship Co-Director
Kymberli Hillman, Internal Medicine Clerkship Coordinator
Date:
Received:
Initial if received:
Internal Medicine Clerkship Manual available online
Received:
Core Medicine Clerkship Curriculum Guide
Handbook for Students and Faculty
Pocket Guide Version 3.0
Book#:
Received:
Book#:
Primer to the Internal Medicine Clerkship
Date received:
Date:
Laptop w/built in web camera for use in Sandersville, GA
Student:
Rotation dates:
*Signature:
*By signing this form, the student is aware that the above books & laptop are the sole property of The Department of
Internal Medicine I Mercer University School ofMedicine. The student acknowledges these books & laptop are being
loaned to him/her while rotating through the 12 week Internal Medicine Junior Clerkship Program and must be returned in
good condition, free of any damage or permanent markings ofany kind, PRIOR to the day of the ShelfExam which is
scheduled for the last day of the rotation.
*Failure to return the books or laptop may result in the student being charged a fee for replacement
and/or the withholding of student's grade for the rotation until the books or laptop are returned.
Date books/laptop returned:
Signature acknowledging books/laptop returned: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __
PLEASE RETURN THIS FORM FOR YOUR FILE TO CLERKSHIP COORDINATOR BEFORE YOU LEAVE.
42
-MERCER UNIVERSITY SCHOOL of MEDICINEJohn A. Hudson, M.D., Internal Medicine Chairman (Interim)
Rossana Carter, M.D., Internal Medicine Clerkship Director
Thomas Hope, M.D., Internal Medicine Clerkship Co-Director
Kymberli Hillman, Internal Medicine Clerkship Coordinator
REFLECTIVE WRITING I OSCE VIDEO PRESENTATION REVIEW
Rotation Dates:- - - - -
Today's date: _ _ _ _ _ _ __
OSCE VIDEO PRESENTATION REVIEW
OSCE Mentor:
Student Name:
OSCE Mentor Signature: _ _ __
Student Signature:
The OSCE video presentation recorded by above named student has been reviewed and discussed with
the student by the above named OSCE mentor.
REFLECTIVE WRITING
Reflective Writing Reviewer: _ _ _ __
Student Name: _ _ _ _ _ _ __
Reviewer Signature:
Student Signature:
The two reflective writing entries by above named student has been reviewed and discussed with the
student.
PLEASE RETURN THIS FORM FOR YOUR FILE TO CLERKSHIP COORDINATOR. THANKS!
43
APPENDIX
Review of Soap Note Charting
and
An excellent example of a complete H&P
44
Review of SOAP Note
Charting
Joseph M Keenan MD
Dept of Family Medicine
Why SOAP N'otes?
i Most of the clinical work we do in medicine is
problern focused.
t About 20 y a~o D r. Lawrence \Need developed
a system of ''Problem orien1e·d medical record"'
chartin9.
l The SOAP note is the fundamental element of
the problem oriented rneclfcal record _
r SOAP notes provide better cornmunrcatf:on
among multiple providers o r over multi pre visits
in patient care
r Proficiency at SOAP note charting is tested in
the USMLE CS test
45
SOAP Notes
rmpo rt:mt and relevant positives
and negatfves from a focused ilx'
r ''S" Su!)jecthle:
"0 " Objective: irnpmtrmt and relevant positive
and negative physical findin9s, test results_
r "A" Assessrnent list of the differentinl diagnoses
in priority of mos· likelv or important as
determined from sana
J "P" Plan~ list of tests or further diagnostic v.1ork
up intended to nmrow, confirm or evaluate dif
dx_Should tnclude only tests or work up
v;a.rranted by Sand 0 , and should be cost
effective_
o_
Other Clinical Performance
Evaluation 1n OSCE
t
l
Patient Rapport-greeting, eye contact
Use of fay language-avoid medical jargon
English proficiency
Counseling and communication skills
Professional/personal manner-wash
hands, proper exam technique, afford
patient modesty
Hand writing legibility, avoid excessive
acronyms
46
Example SOAP note
cc
S: ~c :au:.:~sbm ro,tir;;,;! al.e schoolteacherpr.eSSlls f::>ra rr:o F!U ~fHTN, ,e ;;s
he:= bk'n~ H:::TZ • qd "or 'y. and added a:enclcl 1 ~a rr:· age t:· t) :c irr::··Q,•e
contro . He obt3 •s ou:s·de 3? r.ead·n:-s Occ.J5.'ly au ... :hinks t·~·y run m :he 13D's
syst ar. ::.s a ·:ost BP • t·~ c'fce tOO::llf 0: 1~0 <>o·, ";•er:h:m ·;.sua read 'ngs.
He • "'" noted some decrea~ :n -=r~:ction o. :<I:.> and quan:i:y c·.·er fue ;o;st "' 11c ">hs,
decreased.r. :>c~m;JI and .:.. ',1 e:reo:icns. '.'.'i"e (7 C"C:y ;eems s·
pporh·~
.and •
=
d*sn<t f~l 1 ;ED:O hash, 11he rela.;ionsbip. 1- e YIO :ers if th~ 5P 1eds h;r.·-:: some
e::fecton ·s s.ex f~ nG1ion ;;.nd would ~e :hai a~;:·:-ssed rf possible. H:e has ad r.o
cr.hcstaf c s~·s . a ches1 :;.;;,;·. n ~spnea, orr- :·pnea, edema. l e:~da•;hes,d'::z. • ess,
•.•isu;; pn:b e':ls, joint pa:n mus~e acr:-s,cr dep·essi~·esx's. He dc2S.n'h:i!l :hat t e
has.1. ·due str~ss in • s fe ana :es ·;enera y • appy wit'" h'sreutio .ships a:-:
reliremen: !-e has arela: i~~y :>:>or d e1w::"- '-~quem·3si "oods and has noH:.;oen
ab ~to lose weighbs c~s ·:-:, ·o a:t:nt :o· ~:>salt r~s:rcto·. Sed;,:::tar;r, da~sn't
smok.!: x30::.•.occa; ETOH No {BS<.:>Tha h~ orSl: c" CVA orTIA., cbbet-es .or
p~r't>;.eral vas.."UI3r e :S , t>ol •;, h;;~s h;;:c' an a.ng 'cpasrl · C~· ago f;:.• CAD a•.:. :a ,;,s
[pJt.y· :and .~SA.q.:'. H.: d.J:;n't k now~= dcs.~s c-= any c·f .. -s 'ne-:. :at::."" !:. b"t ::..:.s
llnow whatt,.ey' e 'or .J(l c'f~ls he i s "p·;,t:y gocd • ab·:o.t:al(ng th~;•1 ;:gularfy. Ye·
dc:s ":i.'i? inc·;,as:-: urma-y =r~q•J:: ·y wit· lhi? 1-::TZ bu: unce-;':2nds :t1a: :lia: s
ho1v ir. ,., or~s.
Exampfe SOAP note
i
l
I
l
t
0 : VS ilP 160/96;T 98.0 f ;RR"'161min.; HR=70/mi'l Lind reg.
\~oderatsly <:J•,•en•teight with central obesity, wa f ~t eirc=42in
HEENT fu1ci shc·w moderate asvd c.h::mg;o~. no hen·s cr e:-:ud::1tes .
di~cs sharp, c3rotid p 'JI~es fulf ard equal no bruits, no JVD
Chest: clear to <!him:. No ra'es . norn·til bre3ih sounds
He<!rt: R.~, P ·~1 I in norrn::: I lo cLition end no heave or evid en,;.;; of
co:Jrdtome;ct y·,rormallle;:~rt sounds. no mumt or gaLop
ABD: no bruits over a!Jdom:n3[ ve~se 's, no o:JC"1c. wid1m!ng , no
hepo:Jtosplenomegaly
Extren-ities: gocdfequa, ::;eripheml pJise~ , radklL posUib. and
domafts poo all pal p. , 110 ~phic ~k· n changes.
Cogn'ti·:e 'i.ncifo'l o:Jnd affect nt, Mini r<lenial status nl
47
Examplle SOAP note
A: Hypertension not adequately contro'lled
Qn present meds
1 Er,ectile Dysfunction
l Coronary Artery Disease SIP angioplasty
t Dyslipidemia
Obesity
J P: l~1bs: _N:a+, K+i Cl-, C02, FBS, Uric Acid,
fastmg lrp1d profi e, creat, BUN
1\ Schedule for erectile dysfunction evaluatron,
include ·wife if patient will ing.
r 24 hour BP monitor, sc.iledure rect1eck to eval
BP readings after I£Jbs back; discuss the
importEmce of good BP control and compliance
with meds. Consider '\fll/U for other etiolooies of
HTN as wel.l as adding Rx's if control
inadequate.
l! Dietician referral with vvife for vveight foss and
hea11 heamw diet
48
PROGRESS NOTE
Include the date and perhaps the time. Give the number and name of the problem followed by:
S.
(Subjective)
The patient's report
0.
(Objective)
The clinician's observations
A.
(Assessment) The clinician's interpretation of what is going on
P.
(Plan)
Further plans, diagnostic, therapeutic or educational
Please see below for an excellent example of a complete H&P. This is a good template to follow. We
need to do a better job of documentation and discussion of differential diagnoses and assessment and
plan. The mark of a good Internist is the length of the differential diagnoses. This will also protect
you medico-legally and allow you higher code of billing when you go into private practice.
49
HISTORY AND PHYSICAL EXAM
CC: " Shortness ofbreath and leg swelling. Chest Pain"
HPI: This 49 year old African American Male was seen and examined in the Emergency Room at 3:00pm.
He complains of shortness of breath, leg swelling, and chest pain. The chest pain is located sub stemally
and describes it as" pressure" like with radiation to the left jaw. On a pain scale he grades the pain as a
10110. This began as he came down the steps ofhis house this morning around 7:00am. The pain lasted 10
minutes. He took a sublingual NTG which provided no. relief. The onset of the chest pain was sudden. He
denied any associated symptoms such as diaphoresis, fever, chills, nausea, vomiting, dizziness, orLOC.
There were no alleviating factors. Rest did improve his chest pain somewhat. The chest pain is similar to
that ofhis MI in 2001.
The patient also noticed his legs swelling up to his knees for the past 3 days. This has progressively gotten
worse. The leg swelling was of sudden onset. He h~d a cough . with yellow sputum production associated
with his leg swelling. He denied wheezing, hemoptysis, pleuritic chest pain. He noticed DOE with only 510 steps. He also has PND and 3 pillow orthopnea during the past 3 days which have gotten worse too.
The patient has shortness of breath for the past 3 days with the onset of his leg edema. The shortness of
breath is at rest and with physical activity. This is progressively getting worse. This is similar to his CHF
in 2001. Despite his Lasix at home, the SOB and leg edema are worse.
PMH: HTN 2000
Heart Failure 2001 . MI 2001 , normal
Cath
PSH: Appendectomy
Cardiac Cath 2001 , normal
MEDS: Aspirin 81 mg po q day Coreg 6.25 mg
po bid Lasix 80 mg po bid
50
ALG:NKA
FH: Father died MI age 46
Mother died MI age S5
BrotherHTN
SOCIAL: Smoking 1 PPD for 30 years (Quit 1 month ago)
Denies Alcoholic beverages, IVDU
Did try Cocaine years ago
Married, lives in Hawkinsville, GA
Eats low salt diet
Works as a Music Minister
ROS:
Head: Negative for trautiia,surgery, loss of consciousness
Face: Negative for surgery, Bell's Palsy
Neck: Negative for surgery, trauma, thyroid disease,discdisease Eyes:
Negative for cataracts, RO, glaucoma, glasses
Ears: Negative for surgery, hearing loss, Perforations
Nose: Negative for sinusitis, allergies,. surgery, epistaxis
Throat: Negative for surgery, trauma, tonsillitis, thrush.
CV: Positive for chest pain, shortness of breath, leg edema, past MI Lungs:
Positive for shortness of breath, cough; dyspnea -on excertion Abdomen:
Negative forHH, PUD, hepatitis, colitis, BRBPR, GB disease. MS: Negative
for OA, RA, Gout, surgery
Neuro; Negative for surgery, LOC, AD, MS, paralysis, LBP
Skin: Negative for eczema, psoriasis, BCe, SCC
Immuno: Negative for recurrent bacterial infections
Heme: Negative for dyscrasias,.blood loss, transfusions
Psych: Negative for bipolar, depression, schizophrenia
PE: Vital Signs T 97.2, P91, R 20, BP llSnS 02 Sat 100% NRB
GeneraljPleasant, cooperative, some mild respiratory distress, well developed, Obese,
answering all my query
Head: Normocephalic, atraumatic, hair appears normal
Face: Symmetric, eN 5-7 intact, no drooping, no TMJ click, no sinus
tenderness
51
Eyes; Good D&C O.U., EOMI, no icterus, no sub-conj hemm. Fundus
\Vithout hemm, no papilledema
Ears: Normal pinnae, TM without inj, pus, holes
Nose: Patent nares, no nasal discharge, nasal septum midline
Neck: Good ROM, good carotid pulses, no carotid bruits. Positive JVD at 30
Degrees, positive HJR, no lymphadenopathy
Oro: Patent, no inj, pus, exudates. Tongue midline, moist, dentition good CV: RRR,
Sl and S2. No murmurs. Positive S3 gallop, no S4. PMI displaced
61h res mid axillary line, no thrills, rubs
Resp: No tenderness with palpation of thorax, no signs ofHZV. Positive rales Both
lung bases, no rhonchi, no wheezing. Positive dullness to percussion Both lung
bases.
GI: Obese. Positive bowel sounds all quad, no tenderness, masses, guarding.
Hemoccult negative. No organomegaly, no costoverterbral angle tenderness· MS:
No joint redness, swelling, crepitus. No muscle atrophy
Neuro: Speech is clear. Awake and Alert. Answering all my query. CN 2-12
Grossly intact. 5/5 motor function to upper ext. and lower ext.
DTR 2+ UEILE. No sensory loss with light touch. Tongue midline Without
fasiculations. No paralysis, flaccidity noted. Babinski negative Cerebellar
function intact, no pronator drift
Skin: No g~oss rashes, cyanosis, clubbing
Extremities: 3+ pitting edema bit. Ankles up to knees •. No pre-sacral edema
Moving aU 4 ext. well
Vascular: Good pulses at carotids, radial, femoral, DP, PTalll-2+
. Good cap. Refill, calfs soft bit Positive for some brawny edema
Bilateral lower extremities
Psych: Normal mood and affect
OLD DATA: No old records found in computer system
LAB DATA: MBA < 10
Glue 104, BUN 13, CR 1.2, Na 137, K3 .8, CL 101, C02 28, AG 8, Ca 9.6,
ALP 81 , AST 35, AL T 23, Mg 23, BNP 699
CBC 8.9, Hgb 18.1 ; HCT 53.2, PL T 229,000, MCV 91.8, TC 116, TO 42, HDL 20,
LDL 88 PT 123, INR 0.91, PIT 27.7
UDS: Positive Cocaine
UA: > 300 protein, small hili, Occ. Bacteria
ABO: 7.39/55.6/40/34/6/73%/ FI02 21 %
EKG: Wide complex tachycardia
CXR: Cardiomegaly, Bilateral Pulmonary Edema; Cephalization
ITA Chest: No signs ofPE. Right pleural effusion present
52
AlP: 49 year old African American Male with H/0 MI, CAD now with:
1.0 Shortness ofBreath•
DnX: Heart Failure, MI, Ischemia, pneumonia, valvular disease,
congenital heart anomaly, volume overload
1.1 Congestive Heart Failure• Consider Cocaine induced Cardiomyopathy
• Prior history ofMI, will consider cardiac cath to evaluate for new
ischemia
• Pulmonary Edema evident by increased· JVD; increased markings on
CXR, generous pitting edema, enlarged heart on CXR
•
Start IV Natr~or2mcgiK.g IV bolus, then 0.01 mcglKglmin IV·
Infusion. Monitor UP closely for hypotension
• Start Lasix 40 mg IV q 12 hours
• Daily weights and record. Strict I&O;s'
• Low salt diet less than 2 grams
• Daily CXR, repeat port. CXR tonight
• Bedside 2D Echo now. Dr. James/Hudson to read
• Consult Cardiology
1.2 Pulmonary Embolism•
•
Unlikely in view of negative CTA Chest
However, will provide DVT prophylaxis
53
1.3 Anemia• Unlikely cause of Shortness of breath in view of adequate Hemoglobin
2.0 Chest Pain• DDX:Acute coronary syndrome, PE,
Tension pneumothorax, Aortic Dissection,
Pleurisy, Anxiety, GERD, esophagitis
2.1
Acute Coronary Syndrome-
.12 Lead EKG does not reveal any acute changes to suggest .
ischemia or infarction. Will monitor EKG x 3
• Cardiac biomarkers are not elevated, will monitor 3 sets, 8 hours
Apart. This makes MI or ischemia unlikely
• . Morphine 2-3 mg IV every 5 minutes PRN chest pain. Call MD .
If3 doses are given. Oxygen 100% NRB to keep 02 &.at> 91%
NTG patch transdermalliow. Aspirin 325 mg chewed now.
Lipitor 80 mg po now
2.2 Pneumothorax•
This is unlikely in view of negative CTA Chest and no radiography
evidence on CXR
2.3 Herpes Zoster Virus• No evidence of vesicular lesions noted on thorax during inspection
2.4 Pneumonia•
•
No signs of pneumonia on CXR
Patient not febrile, no leukocytosis
. 2.5 Valvular Heart Disease-
54
•
No clinical past history of rheumatic, scadet fever, to suggest
any valvular pathology or congenital anomoly
3.0 Wide Complex Tachycardia:) in ER• DDX: WPW, A V re-entry tachycardia, V-Tech
• Monitor now shows NSR
• Consider EP study. Will consult EP cardiologist
4.0 Hypoxemia•
•
Consider Respiratory Acidosis by ABG
Consider Congestive Heart Failure.
Will monitor 02 saturation and consider need for BIP AP
Will require out-patient sleep study in view of his high BMI
and consideration of OSA
5.0 Cocaine positive UDS• Will get Psych Liason Consult
6.0 Nicotine Abuse•
•
Will encourage and counsil on quitting
Offer Nicoderm patch as out-patient .
7.0 Obesity• Very high BMI
55
•
•
Will involve nutritionist to get on proper diet plan
Sleep study to access OSA as cause of hypoxemia
John Doe, M.D.
Beeper # xxxx
56
USMLE® : Test Content & Practice Materials
Page lof2
Common Abbreviations for the Patient Note
Note: This is not intended to be a complete list of acceptable abbreviations, but rather represents the
types of common abbreviations that may be used on the patient note. There is no need to use
abbreviations on the patient note; if you are in doubt about the correct abbreviation, write it out.
yo
m
f
b
w
L
R
hx
hlo
cia
NL
WNL
0
+
Abd
AIDS
AP
BUN
CABG
CBC
ccu
cig
CHF
COPD
CPR
CT
CVA
CVP
CXR
DM
DTR
ECG
ED
EMT
ENT
EOM
ETOH
year-old
male
female
black
white
left
right
history
history of
complaining of
normal limits
within normal limits
without or no
positive
negative
abdomen
acquired immune deficiency syndrome
anteroposterior
blood urea nitrogen
coronary artery bypass grafting
complete blood count
cardiac care unit
cigarettes
congestive heart failure
chronic obstructive pulmonary disease
cardiopulmonary resuscitation computed
tomography cerebrovascular accident
central venous pressure
chest x-ray
. diabetes mellitus
deep tendon reflexes
electrocardiogram
emergency department
emergency medical technician
ears, nose, and throat
extraocular muscles
alcohol
http://www.usrnle.org/Examinations/step2/cs/contentlabbreviations.html
5/ 12/2009
USMLE® : Test Content & Practice Materials
Ext
extremities
FH
family history
GI
gastrointestinal
GU
genitourinary
HEENT
head, eyes , ears , nose, and throat
HIV
human immunodeficiency virus
HTN
hypertension
IV
intramuscularly
JVD
KUB
LMP
LP
MI
MRI
MVA
Neuro
NIDDM
NKA
intravenously
jugular venous distention
kidney , ureter, and bladder
last menstrual period
lumbar puncture
myocardial infarction
magnetic resonance imaging
motor vehicle accident
neurologic o
non-insulin-dependent diabetes mellitus
no known allergies
NKDA
NSRPA
PERLA
po
PT
PTT
RBC
no known drug allergy
normal sinus rhythm
posteroanterior
pupils equal , react to light and accommodation
orally
prothrombin time
partial thromboplastin time
SH
red blood cells
TIA
social history
U/A
transient ischemic attack
URI
urinalysis
WBC
upper respiratory tract infection
white blood cells
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